New Health Chinese Medicine Clinic Registration
This form will be used as both a registration form for those coming into our clinic and also a contact tracing form. Details collected in this form will be stored for 28 days for the purpose of contact tracing if required.
Email or Contact Number
Date you are visiting the clinic
COVID-19 Screening and Contact Tracing
Please only tick if this applies to you. If you have any symptoms please alert staff. If you have been in contact with confirmed cases of COVID-19 or have been advised to self-isolate, we politely ask you to book telehealth and look forward to you visiting the clinic again. Thank you.
I have not tested positive for COVID-19, or come in contact with an confirmed cases in the past 14 days.
I have not travelled internationally, interstate, or to any known COVID-19 hotspots in the past 14 days
I understand that the information I have provided will be stored for the purpose of contact tracing.
Outline any COVID-19 symptoms you may have if relevant
COVID-19 symtoms include fever, sore throat, cough, shortness of breath, loss of taste/smell). If doesn't apply please skip
Thank you for taking your time filling in your details for COVID-19 screening and tracing.
On your arrival your temperature will be checked and please wear a mask, follow rules of physical distancing and adequate hand hygiene.
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